Communication pattern between nurses and elderly patients through a neuro-linguistic programming approach

This study aimed to determine the pattern of communication between nurses and elderly patients towards a healthy lifestyle through the NLP approach. It was a qualitative study using a case study method involving 6 nurses and 15 elderly patients active in Prolanis activities in Batu Ke'de village, Masalle subdistrict. The results of observations and interviews were then analysed using interactive analysis techniques from Miles and Huberman. Based on the results of observation and analysis, the study found that nurses could use the neurolinguistic programming method in communicating with the elderly which causes changes in the thinking and behaviour patterns of the elderly towards a healthy lifestyle. Therefore, the NLP method can be used by nurses as one method of communicating and influencing elderly patients by taking into account its four main pillars, which are the outcome, rapport, sensory acuity, and flexibility


INTRODUCTION
Similar to other countries, the number of elderly in Indonesia increases every year to more than 11% of the total population (Wang, Hsieh, & Wang, 2013). Based on data from the Enrekang Regency Central Bureau of Statistics in 2016, the number of elderlies in Masalle Prolanis. Prolanis is a health service system and proactive approach to maintaining the health of BPJS participants with chronic diseases so that they can achieve optimal quality of life with effective and efficient health costs. This activity is carried out every month. It starts with gymnastics and health checks and ends with counselling. However, the implementation of Prolanis in the Masalle District was not welcomed by the community. This can be seen from the reducing number of participants at each meeting and the implementation of a healthy lifestyle that is still far from expectations. Thus, we need a communication approach that can influence the mindset of participants so that it has an impact on the application of healthy lifestyles in their daily lives.
The ability to communicate effectively is a core skill that must be possessed by nurses in carrying out nursing care, such as conducting assessments, evaluation, and documenting actions (Tijani-Eniola, 2016). The nurse's communication skills can be influenced by the level of education, mental conditions, and workload of nurses (Caris-Verhallen, De Gruijter, Kerkstra, & Bensing, 1999). The level of education is related to the patience possessed by nurses, attention, and ability to provide feedback in dealing with patient complaints so that they can communicate in a well, accurate, and effective manner. Nurses with higher education are better at providing information about diseases and health conditions experienced by patients. Meanwhile, the mental condition and workload are related to stress experienced by nurses so that it affects the mood in interacting with patients. Nurses with little workload will focus on creating and maintaining relationships with patients. They will spend more time doing social conversations and affective behaviour than nurses with high workloads.
Effective communication plays a vital role in improving the quality of nursing care provided and the quality of the relationship between the parties involved in communication. This is important because, in addition to conveying information, at a further level, it can encourage changes in the patient's behaviour to a more positive direction (Sitorus & Herawati, 2013). Through the ability to communicate well, patients can make a benchmark for nurses' abilities related to their knowledge and competence, especially when physical contact occurs. Therefore, to increase the effectiveness of communication skills, nurses need to implement and utilize effective communication strategies in providing nursing care (Ahmad, 2014).
Neuro-linguistic programming (NLP) is a new technology in the world of health care that discusses how nerves and languages can work together to change the way people think and behave (Tosey & Mathison, 2010). NLP was first introduced in the 1970s by Richard Bandler and John Grinder. In their research, they involved great communicators and counsellors, who later produced an improved communication approach model. Neuro-linguistic programming (NLP) consists of 3 elements, namely neuro, linguistics and programming (Bigley et al., 2010).
Neurolinguistics is a study of nerves and the human brain with language. Therefore, NLP can be interpreted as an approach through communication in directing human action to change someone by doing mind guidance (Rustan, 2017). NLP has been widely used in communication, self-development and learning approaches (Pensieri, 2013).
NLP can be used to build strategies to encourage health-improving behaviour, to look for why someone can recover faster, to examine model strategies, and to find out who is more at risk of suffering from certain conditions (Steinbach, 1984). NLP can be done by using specific word patterns in describing something so that mental processes that affect behaviour may occur to achieve certain goals (Rustan, 2017). Management of existing information is carried out through optimizing the ability of the brain by strengthening neuron circuits with nerve stimulation that coordinates the role of memory related to the human senses, especially vision, hearing, taste, smell, sensory language sensation through the recipient's senses of motion stimulation and feelings or emotions (Sturt et al., 2012). In approaching the NLP method, one must understand and apply the four main pillars of NLP, which are the outcomes, rapport, sensory acuity and flexibility (Dove, 2004).
The "outcome" means that those who are communicating must understand the goals of communication and how to achieve those goals (Pensieri, 2013). Before starting the communication, one must first identify the desired goal or result, such as talking about what, conveying what message, and whether the message delivered is true and useful for the interlocutor. Full understanding of the results one want to get greatly helps the process of achieving communication goals (Tijani-Eniola, 2016). One can achieve excellent communication when interactions are meaningful and directed (Matusitz, Breen, Zhang, & Seblega, 2013).
Rapport is defined as a respectful and accepting approach when interacting with others (Dove, 2004). The approach can be verbal or nonverbal. The result of the approach taken is the establishment of a trusting relationship. Fostering a trusting relationship between nurses and their patients begins at the introductory or orientation stage (Liljeroos, Snellman, & Ekstedt, 2011). Trust is the core of effective communication (Wood, 2006). One way for the nurses to build trust is to mimic the patients, for example, by imitating their body language, breathing patterns, smile, eye contact, as well as exuding empathy and good intentions (Lang, 2012;Wood, 2006). If a good relationship is established, communication will be more natural and smooth (Matusitz et al., 2013).
Sensory acuity is the ability to use the five senses to carefully observe other individuals without certain assumptions or judgments beforehand so that individuals can give a maximum rapport response (Micciche & Lancaster, 1989). When communicating, a nurse must see the patient's verbal and non-verbal responses (Caris-Verhallen, Kerkstra, & Bensing, 1997). Sensory acuity includes skin colour, body posture, breathing patterns, and facial expressions (eyes and lips), and patient body movements (Tosey & Mathison, 2010). By understanding the responses of the communication partner, we can be involved in meaningful communication (Matusitz et al., 2013). Situations and conditions during communication are also crucial. A conducive environment can help the partner to feel calm and focus on what is being communicated .
Flexibility is about determining the choice of methods used in communication (Dove, 2004). Flexibility is needed by nurses to achieve the desired end result (Thompson, Courtney, & Dickson, 2002). Flexibility includes the choice of words, sentences, and ways of delivering them (Weirather, 2010). Nurses are required to be able to adjust their communication technique according to the needs and abilities of patients. Indeed, the way to communicate with elderly patients is different from communicating with adult patients. Cognitive disorders in the elderly require communicators to slow down interactions and to be patient (Weirather, 2010). Repetition and use of appropriate language are also essential (Bigley et al., 2010;Hummert et al., 1992).
The use of the same and easy to understand language helps to promote communication (Wang et al., 2013). Language is undoubtedly one of the biggest deterrents in communication (Lang, 2012). A person can feel motivated, bored, ready to learn, ready to improve behaviour, or indifferent just by listening to spoken words because it can evoke strong emotions and actions (Bashir & Ghani, 2012). Besides, the way to communicate in communication must also be considered. In order to avoid the patients' boredom, nurses can construct communication aids by using attractive media such as leaflets, PowerPoint, or by direct practice (Dixon, Parr, Yarbrough, & Rathael, 1986).
NLP has been widely used in communication approaches by health practitioners (Pensieri, 2013). A previous study conducted by Sturt et al. (2012) entitled "Neuro-linguistic programming: A systematic review of effects on health outcomes" found the influence of behaviour change in patients with approaches taken by health practitioners using the NLP technique. Furthermore, Pensieri (2013), through his research entitled "Neuro-linguistic Programming In Health: An Analysis of Literature," suggested that health practitioners can use NLP in communicating with patients as a therapy for patients.

METHODOLOGY
This research was a qualitative study using a case study method. With this method, researchers observed and analysed how nurses communicate patterns to elderly patients using the NLP approach. The sample selection technique was purposive sampling. We selected 3 out of the 6 nurses who worked on Prolanis activities in Batu Ke'de Village from January to June 2018. Meanwhile, the elderly group observed was originated from Batu Ke'de Village, with a total of 15 people. This research was conducted on Prolanis activities in the Masalle Community Health Center work area, namely Batu Ke'de village, Masalle Subdistrict, Enrekang District, South Sulawesi Province from 12 January to 15 June 2018. The researchers participated in Prolanis activities carried out every month by health centre staff which consists of doctors and nurses. Data were obtained through observations and interview techniques with nurses and elderly patients. The researcher observed the interactions that took place at each meeting and conducted interviews with respondents at the sixth meeting in June. The data were analysed using interactive analysis techniques from Miles and Huberman, which consists of three components, namely data reduction, data presentation, and data withdrawal and conclusion. The participants of this study signed a consent form before participating in the study. Confidentiality is guaranteed by encoding all data names. Those codes were stored separately. Participants were told that they could refuse to answer any question and stop the interview at any time.

Respondents data
Demographic data collected shows that the majority (67%) of the respondents were above 65 years. Most (73%) of the sample were women. The majority of patients suffered from hypertension (73%). Regional languages were languages that were more widely understood (53%). Although some did experience communication barriers in speaking and listening, 53% of the participants had no problem. The majority of nurses in this study were women (83%) aged 25 to 45 years old (83%). Most had expert education level (67%), and all of them (100%) spoke Indonesian and regional languages.

NLP pillars:
Good communication affects patients' psychological condition (Street, Makoul, Arora, & Epstein, 2009). Communication can help reduce the anxiety experienced by patients (Lang, 2012;Street et al., 2009). Neuro-linguistic Programming can be used to influence a person's mindset, which can promote changes in a person's behaviour patterns. One technique that can be used by nurses is persuasive techniques. In applying persuasive techniques using the NLP approach, nurses are required to understand and implement 4 NLP pillars, namely: outcomes, flexibility, sensory acuity, and rapport.

Outcome
Before interacting with patients, Nurses must first understand the goals of the interaction. A nurse explained that …my friend and I are aware of doing Prolanis activities to increase the awareness of the elderly to live a healthy lifestyle so that it will focus on how the elderly can change their mindset and apply healthy lifestyles in their daily lives by paying attention to nutrition, physical activity and routinely check themselves into health services. (N1, 2018).
By understanding the objectives to be achieved, the nurse can determine what material will be delivered. This was prevalent in several statements: "we prepared and mastered the material first" (N5, 2018); "... using the Indonesian Language" (N2, 2019), "the topic of counselling was changed every meeting according to the needs of the elderly" (N6,2018). The purpose of understanding the activity's objective is to make it easier for nurses to interact with patients and to achieve such an objective. An elderly person said, "I was able to understand what the nurses and doctors said" (P1, 2018), "I have limited the intake of sugar and salt according to the recommended diet" (P6, 2018), "I want to be healthy, so I have to change" (P10, 2018).
Researchers see conditions when nurses interacted with patients where communication ran smoothly. An introduction preceded the delivery of the material. Next, the nurse explained the counselling material using the local language. The nurse mastered the material presented, and the patient understood it. Therefore, the nurse can direct the elderly to the objective of communication, which is to change patterns of thinking about a healthy lifestyle and motivate them to apply it.
Based on the above analysis, it can be concluded that nurses have fulfilled the one NLP pillar, which is the outcome in interacting with elderly patients. By understanding the purpose of communication, nurses can change the patterns of thought and behaviour of the elderly by providing appropriate material and using exciting and easy to convey delivery method.
Before starting communication, the nurse first identified the communication objectives, what material will be delivered, and how to deliver it (Tijani-Eniola, 2016). The nurse can determine the material to be submitted and how to convey the material both in terms of patience, language, and methods to be used (Wang et al., 2013). By applying the NLP principle, which is determining the goal, it is easier for nurses to communicate with the elderly so that the communication process runs smoothly and accordingly (Fridriksson, Nettles, Davis, Morrow, & Montgomery, 2006). This research is in line with Pensieri's (2013). When the nurses genuinely understand the final results of the communication made, they can easily direct all communication to the final results. Nurses' understanding of the final results also helps in identifying the effectiveness of communication (Bashir & Ghani, 2012).

Rapport
Based on the results of interviews with nurses, this study found that "what is done during the orientation phase with the patient is asking about the patient, introducing themselves, asking the patient for approval, contracting time and place of interaction to foster a trusting relationship with the patient" (N3, 2018). Fostering a trusting relationship is fundamental in applying persuasive techniques for patients. A nurse stated that "sometimes there is a difference in the response of patients who have known officers and those who do not know the officer especially if the interaction exceeds the time contract that we agree on, patients are sometimes bored and anxious" (N1). Besides verbal communication, nurses can maintain eye contact and smile to patients while communicating. By maximizing the nurses' verbal and nonverbal communication skills, the patients' trust can be obtained, so that the patient will be more open. A similar point was observed in an elderly patients' statement: "When I speak, nurses really pay attention to what I say so I feel happy to tell complaints that I often experience" (P2). Some said that "I feel happy if at the beginning of the meeting we shake hands, ask how we are, always smile and are willing to listen to our complaints" (P3).
From the observations of researchers, nurses were able to foster trusting relationships with patients. This can be seen from the increase in the number of visits in each Prolanis activity and health services. Likewise, an improvement was observed in patients compliance with their diet and willingness to participate in elderly gymnastics, especially during Prolanis activities. To foster a trusting relationship with the elderly, nurses maximize verbal and nonverbal communication. The nurses showed empathy and manners to make the elderly patients also felt valued. Also, when interacting with the elderly patients, the nurse paid attention to these factors: the distance from the patient, the body posture occasionally bends, maintaining smiles and eye contact, and not folding their arms. Based on the above analysis, it can be concluded that by fostering a trusting relationship with patients, persuasion techniques can be done well. The patient will feel happy and willing to follow the advice given by the nurse. Thus, the purpose of the interaction can be achieved.
Fostering a trusting relationship begins from the introductory stage until verbal or non-verbal communication is completed (Ahmad, 2014;Liljeroos et al., 2011). This result is supported by research conducted by Wood (2006) which stated that building trust from patients can be done by maintaining eye contact and smile and adjusting posture and body movements.
Showing polite and courteous attitudes is also very influential in fostering a trusting relationship, mainly because the interlocutor of the nurse is an elderly (Ahmad, 2014;Kourkouta & Papathanasiou, 2014). In addition, with trust and honesty, communication will be more natural and the information delivered will be more easily accepted by listeners (Kourkouta & Papathanasiou, 2014;Matusitz et al., 2013). A good

Number of Visits
relationship and mutual trust between patients and nurses will help in the effort to provide the best nursing care (Ahmad, 2014). When the patient has trusted the nurse, the patient will explain openly, and in detail, the information needed by the nurse and vice versa. The patient will feel safe and comfortable with the nurse. Another thing that should be considered by nurses is trying to create a conducive environment when interacting with patients. Note that the environmental conditions also dramatically affect the concentration of patients, especially the elderly. Elderly patients, in general, experience a decline in cognitive abilities, making it difficult to understand new information. A noisy environment will hinder communication with patients Passalacqua & Harwood, 2012).
The results of the study showed that applying the NLP principle of building trust in communication facilitated nurses in communicating with the elderly and helped to achieve the purpose of communication.

Sensory acuity
Sensory acuity is the ability to use the five senses to observe other individuals carefully without certain assumptions or prejudice so that response can be made with maximum rapport. From the results of observation of researchers, nurses were able to assess the patient's response during communication. It was observed that the nurses were able to respond to patients who felt embarrassed, bored, sleepy, happy, or disagree with the nurses.
Based on the results of interviews with nurses, it was found that nurses had been able to assess the patient's response. The nurses stated that "in patients who are bored listening to the information delivered will show a flat expression, eye contact is less and seems nervous" (N5, 2018). The nurse's ability was also supported by the patient's statement, …when I disagreed with what was revealed by the nurse I put on a sullen look, but the nurse was able to see it and asked my opinion about diet information that I should do as a person with diabetes and hypertension. (P1, 2018) This situation was further confirmed by another patient's statement, "nurses were very much on guard when they talked, when it was noisy they stopped talking and continued again when the situation was calm" (P4).
By looking at the response given by the patient, the nurse needs to respond to the response so that communication can continue smoothly. It was done in several ways: "when I want to talk to an elderly person who looks down shyly, I touch the shoulder of the elderly then talk and nod softly when asking the patient to express his opinion" (N1, 2018) or "by maintaining eye contact and smiling while talking to patients, patients looking happy so that it also gives positive feedback" (N2, 2018). Therefore, it can be concluded that nurses were able to assess and address patient responses adequately, both verbally and non-verbally. This capability supports smooth communication.
The main goal of effective communication is one's ability to interpret messages and respond appropriately. Nurses are required to be good listeners and observers (Ahmad, 2014). Patients are the main focus of nurses in interaction (Wang et al., 2013). Nurses must be able to assess and respond to patient responses, both verbally and nonverbally. When the nurse is unable to assess the patient's response, the communication will be disrupted. The nurse will be busy talking while at the same time, the patient will be busy with their thoughts and no longer focused on listening to the information. Eventually, it results in the communication objectives not being achieved optimally.
In responding to patients, nurses can use the sense of touch to provide comfort and hope for patients (Ahmad, 2014). nurses should also consider creating a conducive environment during communication, as noise can interfere with a patient's concentration Passalacqua & Harwood, 2012). This research is supported by the research of Matusitz et al. (2013) which stated that if someone understands the other's response through verbal and nonverbal symbols, meaningful communication can be created so that the message can be conveyed well.
The results of this study indicated that the nurses' application of sensory acuity NLP principle or the ability to assess the response of elderly patients promotes excellent communication.

Flexibility
Based on the observations, it was found that the nurses applied flexibility when communicating with patients by changing the communication methods if they encounter obstacles in communication.
The interview results showed that flexibility could be done by evaluating the current method and then replacing it with another more effective method. It was observable in the nurse's statement: …every time we finish giving education and motivation, we evaluate how the understanding and desires of the elderly to want to change. If they give a response that is not as expected, we repeat and change the communication style that we do. For example, we invite patients to be diligent in exercising, but patients respond for many reasons, so we practice elderly gymnastics directly after giving counselling (N3, 2018).
Other nurses also stated that flexibility could be achieved by making media and methods of communication, "…to attract the attention of my elderly people using power points, leaflets and each meeting interspersed with various types of elderly gymnastics" (N6, 2018). Another nurse gave a similar statement, "in the discussion, I gave appreciation to the answers given by the patient as well as when asking patients to demonstrate elderly exercise" (N5, 2018). Besides, flexibility can be done by giving a concrete example, as revealed by another news, "as a role model and initial step in promoting to the elderly about healthy food intake we provide healthy food such as boiled corn, boiled yams, or fruits and water white at each Prolanis meeting " (N1, 2018).
The implementation of flexibility carried out by nurses was also reinforced by the patient's statement that "my friends and I were happy to come to Prolanis because the officers carried out counselling in a fun way, especially the gymnastics" (P4, 2018), "the officers were not bored repeating the explanations given and were very helpful because I have a little difficulty in understanding the information" (P2, 2018). By applying the flexibility pillar, communication can progress towards the goal. A patient expressed this: "I got a gift from the nurse because I have been diligent in participating in Prolanis and routinely going to the public health centre for control so that other friends also begin to come and control the Public Health Centre" (P5).
Based on the analysis above, it can be concluded that nurses were able to apply flexibility pillar, which promoted smooth communication and brings the desired end result closer. Nurses used language that can be easily understood by the elderly and used various media in delivering material. By using the same language as the elderly patients, the nurses help them to understand the content of the information (Bigley et al., 2010). Providing examples both directly and through an image or media can spark the interest of the elderly and discourage misunderstanding of the information provided (Bigley et al., 2010;Dixon et al., 1986;

CONCLUSION
In improving the health status of the community, especially the elderly, nurses act as educators and motivators. Nurses are required to have good communication skills so that the message delivered can be well received by elderly patients. Communication in nursing plays an essential role in each stage of the process. One method used by nurses in communicating with patients is the NLP approach. Health practitioners have widely used NLP in carrying out communication approaches to patients. In order for patients to be able to receive information and want to change their behaviour according to what is expected, nurses need to master the four main pillars of NLP, namely outcomes, rapport, sensory acuity, and flexibility. The outcome means the nurse must know the goals of the communication before interacting with elderly patients so that communication becomes more directed. Rapport is the establishment of a trusting relationship between nurses and patients beginning from the orientation phase. Rapport is essential so that patients can be more open in providing health information. Sensory acuity is related to the ability of nurses to respond to verbal and nonverbal reactions that always occur throughout the interaction. Whereas flexibility is the choice of the communication method used. This can be achieved by evaluating the communication so that if there is any discrepancy, the nurse can make changes to the style of communication.
In conclusion, the NLP method can be used by nurses as one of the communication methods in fostering relationships of mutual trust and educating elderly patients. Nurses should pay attention to the four main pillars of NLP, namely, outcome, rapport, sensory acuity, and flexibility.